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WALMART PHARMACY 10-5169
DSH330180 SAMARITAN HOSPITAL
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Covered Entity Details
Entity Name
SAMARITAN HOSPITAL
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH330180
Entity Address
2215 BURDETT AVE
TROY, NY 12180
Medicare Provider Number
330180
Participating Start Date
1/1/2019
Last Recertification Date
8/27/2024
Pharmacy Details
Pharmacy Name
WALMART PHARMACY 10-5169
Pharmacy Address
2252 NORTH 8TH STREET
SUITE A
ROGERS, AR 72756
Pharmacy Comments
Contract Details
Approval Date
7/7/2023
Contract Begin Date
10/1/2023
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
6/20/2024
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Lori Santos, CFO
(518) 525-5537
Contract Pharmacy Representative
Walmart
Julie Howard, 340b Program Manager
(479) 739-1973 Ext: 4792771498
Signed By Date
7/7/2023
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